Endotracheal intubation

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1. ENDOTRACHEAL TUBES and INTUBATION Dr Nisar Ahmed Arain Assistant Professor Anesthesia/Critical Care/ER

2. -INDICATIONS --A =Airway Protection =Optimization of gas exchange --B =Oxygenation / Ventilation =To Decrease Metabolic Demand --C =To Reduce work of breathing

3. - INDICATIONS =Airway protection =Decrease LOC =Lower cranial nerve palsy A =Laryngeal edema =Orofacial injury =Copious trachea-bronchial secretions

4. - INDICATIONS =Optimization of Gas exchange Oxygenation / Ventilation B =Hypoxic Respiratory Failure Pneumonia / Pulmonary edema/ARDS =Hyperbaric respiratory failure Obstructive airway disease/ OSAS Obesity hypoventilation syndrome

5. - INDICATIONS =To decrease metabolic demand/ To decrease WoB -C =Severe septic shock / Burn / polytrauma

6. -Anatomy of airway

7. -Conditions associated with difficult intubation -Congenital anomalies Pierre Robin Syndrome, Down’s Syndrome -Infection in airway Retropharyngeal abscess, epiglottis -Tumor in oral cavity or Larynx -Enlarge thyroid causing compression / displacement of trachea

8. - Conditions associated with difficult intubation --Maxillofacial cervical of laryngeal trauma --Temporomandibular joint dysfunction --Burn scar at Face and Neck --Morbidly obese or pregnancy

9. -Airway assesment -Inter Incisor distance > 3 cm

10. - Airway assesment -Mallampati classification --Difficult Intubation

11. - Airway assesment -Laryngoscopy View -Difficult Intubation

12. - Airway assesment -Thyro mental distance > 6 cm -Difficult Intubation

13. -Airway assesment -Flexion / Extension of Neck

14. -Airway Assesment -Movement of Temporomandibular joint (TMJ) -GRINDING

15. -EQUIPMENTS --Laryngoscope with relevant size blade --Magill's Forceps --Flexible Introducer --10 to 20 ml syringe --Oropharyngeal airways –All sizes --Tape or adhesive Plaster --E.T tubes--relevant sizes --Bag—Valve—Mask with oxygen connected --Suction unit with Yankauer nozzle and endotracheal suction catheter

16. -Laryngoscope

17. -Laryngoscope

18. -Endotracheal tube

19. -Oropharyngeal / Nasopharyngeal Airway

20. -Endotracheal Tube: Size( mm Internal Diameter) --New Born—3 Months = 3.0 mm ID --3 to 9 Months = 3.5 mm ID --9 to 18 Months = 4.0 mm ID --2 Years to 6 Years = (Age/3) + 3.5 -- >6 Years = (Age/4) + 4.5 --Adult Male = 8 to 8.5 mm ID --Adult Female =7.0 to 7.5 mm ID

21. -Depth of endotracheal tube : should be placed at Mid trachea or below vocal cords = 2 cms --Adult -> Male = 23 cms --Adult -> Female = 21 cms --Children a- Oral endotracheal tube = (Age/2) + 12 cms b- Nasal endotracheal tube = (Age/2) + 15 cms

22. -Technique of endotracheal Intubation The three Axis : Oral, Pharyngeal and Laryngeal

23. -Sniffing Position : Aligning the three Axis

24. -Technique of endotracheal Intubation --Position the patient supine, open the airway with a head- tilt-chin-lift maneuver. (suspected spinal injury, attempt Nasotracheal intubation spine in neutral position -- Open mouth by separating the lips and pulling on upper jaw with the index finger

25. - Technique of endotracheal Intubation --Hold laryngoscope in the left hand, insert scope into the mouth with blade directed to right tonsil. --Once right tonsil is reached, sweep the blade to the midline keeping the tongue on the left. --This brings the Epiglottis into view. “DO NOT LOOSE SITE OF IT “ --Advance the blade until it reaches the angle between the base of the tongue and epiglottis (Vallecular space) --Lift the laryngoscope upwards and away from the Nose – towards the chest. This should bring the vocal cords into view. It may be necessary for a colleague to press on the trachea to improve the view of the larynx

26. - Technique of endotracheal Intubation cont. --Place the ETT in the right hand. Keep the concavity of the tube facing the right side of the mouth --Insert the tube watching it enter through the cords. --Insert the tube just so the cuff has passed the cords and then inflate the cuff --Listen for air entry at both apices and both axillae to ensure correct placement using stethoscope

27. -CONFIRMATION OF PROPER TUBE PLACEMENT --PLACEMENT UNDER VISION --FOUR QUADRANT AUSCULTATION --CAPNOMETERY / CAPNOGRAPHY --VENTILATOR GRAPHS

28. -- GOLDEN RULES OF INTUBATION --Always have a suction unit available --An intubation attempt should never exceed 30 seconds --Oxygenate the patient Pre and Post intubation with a Bag-valve-Mask and monitor SpO2 continuously --Have sedative / analgesic medicines available --Always confirm tube placement by more then one methods --Do not attempt intubation unless you are totally skilled, rather perform Bag-Valve-Mask Ventilation --Always confirm tube placement from time to time